LETTER TO THE EDITOR Year : 2022  |  Volume : 42  |  Issue : 2  |  Page : 148-150

Unusual Triggers for Erythema Multiforme

Manal Alsabbagh MB BCh BAO, LRCP and SI (NUI), PgDip and MSc (Cardiff) 
Jordanian Board in Dermatology and Venereology, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain

Date of Submission15-May-2021Date of Decision07-Jun-2021Date of Acceptance14-Jun-2021Date of Web Publication19-May-2022

Correspondence Address:
Manal Alsabbagh
Jordanian Board in Dermatology and Venereology, King Hamad University Hospital, Busaiteen, P.O. Box 24343, Al Muharraq
Kingdom of Bahrain

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ejdv.ejdv_20_21

How to cite this article:
Alsabbagh M. Unusual Triggers for Erythema Multiforme. Egypt J Dermatol Venerol 2022;42:148-50

Erythema Multiforme is cardinally triggered by infections; however, other reported triggers of erythema multiforme include contact with topical therapies, heavy metals, and herbal agents [1]. Clidinium bromide 2.5 mg plus chlordiazepoxide 5 mg, and simethicone 42 mg (activated Dimethicone) are uncommon triggers. Herein, we are reporting a 32-year-old lady who developed erythema multiforme after ingesting these medications as prescribed for irritable bowel syndrome.

In 2017, the patient was diagnosed with irritable bowel syndrome. She was started on two tablets of clidinium bromide 2.5 mg plus chlordiazepoxide 5 mg for 2 months which relieved her symptoms without adverse effects. In October 2020, she was prescribed simethicone 42 mg three times a day for her irritable bowel symptoms, which she took for 2 weeks. Her symptoms failed to improve, and accordingly, she was prescribed two tablets of clidinium bromide 2.5 mg plus chlordiazepoxide 5 mg twice a day again, which she consumed for 2 days until she developed an itchy burning rash on palms and soles, as well as a painful swelling of the lips. The patient forgot to take the medicine (Clidinium bromide 2.5 mg plus chlordiazepoxide 5 mg) in the following days, and thus, it was stopped by the patient. She visited the emergency room twice where she was diagnosed with hand-foot-and-mouth disease. She denied any fever, history of cold sores, being in contact with sick people and taking any other medications. As her symptoms persisted and her oral lesions worsened, she visited the emergency room for the third time when she got referred to the dermatology as a case of hand-foot-and-mouth disease.

The initial consultation was a ‘teleconsultation’ as the physicians were adhering to the COVID-19 restrictions. However, following the revision of the photographs sent by the patient ([Figure 1]), she was advised to immediately attend the clinic. Clinical examination revealed sloughing that was localized to lips and buccal mucosae, along with multiple merged target lesions localized to palms and soles. Other body parts were unaffected. Following the symptoms displayed upon clinical examination, the diagnosis of erythema multiforme was made. As she was tolerating oral intake, we started her on daily prednisolone 40 mg, omeprazole 20 mg, topical steroids, and cetirizine 10 mg during the night. A follow-up session with the patient indicated a significant improvement in her condition ([Figure 2]). We tapered prednisolone over the next 4 weeks, and her symptoms resolved uneventfully.

Figure 1 Lesions on the day of presentation: sloughing of lips (a), targetoid papules and macules on soles (b), and palms (c).

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Figure 2 Lesions after 1 day from starting treatment: reduced sloughing of lips (a) and subsiding palmoplantar erythema (b and c).

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Given that our patient received two medications within a short period of time, the first being clidinium bromide 2.5 mg plus chlordiazepoxide 5 mg, allowing for potential sensitization, and the second, simethicone 42 mg, was started 2 weeks before the onset of the rash, it makes the identification of the exact trigger of erythema multiforme challenging.

To the best of our knowledge, there are only two reports on chlordiazepoxide-triggered Steven-Johnson Syndrome [2],[3] and none on simethicone. However, Johnston and colleagues reported a neonatal case of erythema multiforme with a history of respiratory symptoms. The patient was on occasional oral dimethicone for colic. The course of the disease continued to worsen for two weeks and then regressed with complete resolution. Although the patient had respiratory symptoms, a septic workup (skin, urine, eye, stool, and blood) and viral serology were all negative, including serum antibodies against herpes simplex virus. We suggest dimethicone as a potential trigger in that case [4].

Ethical approval obtained from Research Department in King Hamad University Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Hafsi W, Badri T. Erythema Multiforme. StatPearls. Treasure Island, FL: StatPearls Publishing; 2020.  
    2.Jawaro T, Kumar A, Pistun O, Dixit D. Stevens-Johnson syndrome associated with chlordiazepoxide. J Pharm Technol 2018; 34:82.  
    3.Huang PH, Tsai WJ. Chlordiazepoxide-induced Stevens-Johnson syndrome. J Chin Med Assoc 2005; 68:276–278.  
    4.Johnston GA, Ghura HS, Carter E, Graham-Brown RA. Neonatal erythema multiforme major. Clin Exp Dermatol 2002; 27:661–664.  
    
  [Figure 1], [Figure 2]